With thanks to Dr Kat Smith, paediatric registrar and education fellow at King’s College Hospital….

The somewhat red, somewhat swollen eye is a relatively common presentation in children, and distinguishing between peri-orbital and orbital cellulitis hinges closely on an examination which can be difficult to perform in young children who cannot communicate pain on eye movement or subtle changes in vision.

The orbital septum is key in differentiating between peri-orbital and orbital cellulitis, and in dictating management. For those of us who haven’t thought about it since medical school, it is an extension of the periosteum of the frontal plate of the upper eyelid; a tough structure, where infection cannot pass from front to back unless the septum is breached by a sharp object. However, the orbital septum is not as thick and well developed in infants as it is in older children and adults, and so is not as effective a physical barrier in this age group.

Peri-orbital (or pre-septal) cellulitis is inflammation and infection of the eyelid soft tissue superficial and anterior to the orbital septum; the septum itself is not affected. Ocular function remains intact.

Orbital (or post-septal) cellulitis is infection of muscles and fat within the orbit, posterior to the orbital septum; the septum itself can be affected. It’s location in muscles and fat leads to associated ocular dysfunction.

What’s different in children?

Children are twice as likely to develop periorbital and orbital cellulitis in comparison to adults, and whilst in adults peri-orbital cellulitis is usually secondary to a superficial injury, children may develop it secondary to an occult underlying bacterial sinusitis (in particular, through the thin and porous ethmoid bone; there is often a history of recent URTI) or due to spread from another primary infection, such as pneumonia.

This difference in underlying aetiology means that in children a peri-orbital infection can rapidly progress to the much more concerning condition of orbital cellulitis, with the associated risk of rare but serious complications such as abscess formation, cavernous sinus thrombosis, intracranial abscess, and loss of vision.

Examination

The happy, well-looking child who is able to open their eye sufficiently for you to demonstrate normal light reflexes and see that they comfortably move their eyes in all planes more than likely has peri-orbital cellulitis; this will be most children. However, there are red flags that make orbital cellulitis a likely diagnosis and should prompt urgent referral to secondary care:

– Eyelid swelling such that the eye is not visible

– Toxic / systemically unwell

– CNS signs or symptoms

– Severe / persistent headache

– Pain on pressing the closed eyelid, indicating septal involvement

– Pain on eye movement, indicating involvement of muscle and / or fat

– Diplopia; older children should be able to describe “seeing double”, younger children may become unsteady when walking or struggle to grab objects

– Reduced visual acuity; the younger child may struggle to play with smaller / more “fiddly” toys

– Proptosis

– Ophthalmoplegia

– Absent light reflexes

– No improvement or worsening despite 48hrs oral antibiotics

– Neonatal age group (may be congenital dacryocystitis)

Management

Most children will be well, with mild-moderate swelling and erythema and no red flags; these children can initially be managed in the community, and most will not require later referral to secondary care.

Children with mild-moderate eyelid swelling, no significant erythema and an obvious cause – such as a chalazion or insect bite – do not have peri-orbital cellulitis, although they may need advice or treatment for the underlying cause such as warm compresses or anti-histamines.

Those with mild to moderate swelling, erythema and no obvious cause but no red flags are likely to have peri-orbital cellulitis and so require oral antibiotics; typically a 5-7 day course of co-amoxiclav is given, although this varies dependent on local microbiology guidance. Because of the underlying aetiology of peri-orbital cellulitis in children, parents should be advised that if children develop any red flag symptoms they require immediate medical review, and a GP review should be arranged for 48 hours’ time to ensure that symptoms have started to improve.

It can be unclear in young children if they have any red flags; if in doubt, refer to secondary care for review by ophthalmology, A&E, or paediatric teams. Even in secondary care it can be unclear, and children may be admitted simply for oral antibiotics and observation. ENT teams will also need to be involved if orbital cellulitis is suspected.

As above, children with any red flags are likely to have orbital cellulitis and will likely require admission to hospital for blood tests, cultures and IV antibiotics +/- imaging of the sinuses and orbits (although more extensive neuroimaging is indicated if there is a suspicion of cerebral infection).

References

“Children are twice as likely to develop periorbital and orbital cellulitis in comparison to adults”

We have seen a lot of cases of scarlet fever this year so thanks to Dr Lock for his text box this month on recognising and managing this strep infection. Comprehensive information on paediatric dizziness from Mr Sharma, ENT registrar, and a bit about asthma in schools and some of my own CPD on birthmarks caused by a Mum whose view that the internet knew more than me was a little unsettling – for a while. We have all been there, I’m sure.

August’s PDF only has 4 text boxes but with lots of information crammed into them and extra on the blog. A great looking PDF on poisoning in children from one of our registrars, an article on stammering from another working with a speech and language therapist and an update on BTS pneumonia guidelines just in time for the winter. Also a feature on Cardiff’s core info safeguarding work on the evidence behind different types of fractures. Do leave comments…

June’s PDF digest is ready for consumption. Both APLS and NICE have lost paraldehyde from their status epilepticus algorithms, a link to Working Together and an article on sticky eyes v. conjunctivitis. Blood pressure centile charts and a plug for the London Deanery’s communication skills courses. Do leave comments below.

Fever, both in primary and secondary care is a frequent presentation. Often, it is a sign of an illness and in the first instance, it is important to establish the most likely underlying causative factor. Once this has been determined, focus often turns to the management of the fever. Two recent articles in Archives highlight the varying practice amongst clinicians both in primary and secondary care.

In accordance with NICE guidelines1, the authors2-3 suggest anti-pyretics should not be used for the sole purpose of controlling fever. Agents such as paracetamol and ibuprofen are often administered to promote comfort in the child when there is fever. In such situations, children may be prescribed single or dual therapy.

In a systematic review, E.Purssell3 examines the evidence for combined anti-pyretic therapy with either paracetamol or ibuprofen alone. He concluded that ‘only marginal benefit was shown for the combined treatment compared with each drug individually which, taken alongside the risk of overdose and further increasing the fear of fever, suggests there is little to recommend this practice’.

With the real risk of parents being unable to accurately measure medication4, it is important clear guidance is given on when and what type of drug therapy is appropriate in clinical situations.

Had another fatal Meningococcal B case a few weeks ago. Always upsetting. Text book management by the night team, excellent support and fast action by CATS retrieval team, the full services of one of the top PICUs in the country – but that horrible little diplococcus won the battle. Of course it didn’t really, our antibiotics would have killed it off pretty quickly, but the cascade it had set in motion was irreversible. 2 of the juniors involved with the case have separately presented it and looked into aspects of it further – a mark of how deaths like this have an effect on every member of the team. Dr Keir Shiels looked at prophylaxis and secondary prevention:

Neisseria meningitidis is found in the throats of around 15% of the population and is the cause of the much-feared meningococcal septicaemia. The incidence of meningococcaemia has fallen significantly since the advent of vaccines against some strains; and public awareness of the danger of non-blanching rashes is high.

Despite the relatively high prevalence of N. meningitidis as a commensal organism in the population and the relatively low incidence of meningococcaemia, meningococcal sepsis is still a notifiable disease. This stems from the pre-vaccine days when Men A was able to spread epidemically. The HPA still recommends prophylactic antibiotics for contacts of a patient with meningococcaemia.

A recent Cochrane review has been published regarding the effectiveness of different antibiotic regimens in obliterating N. meningitidis from the throats of inoculated hosts. The study has compared the effectiveness of Rifampicin, cefalosporin and Ciproflaxacin and comes to several conclusions which have altered UK HPA Guidelines.

The increasing risk of rifampicin-resistant N. meningitidis, plus the reduced likelihood of compliance with a twice daily prophylaxis for two days, means that for adults and older children, rifampicin is no longer the antibiotic of choice. The HPA now recommend ciproflaxacin to be given as a single one-off dose instead. It is believed that this is at least equally effective, but with far better compliance.

People who require prophylaxis remain as: first degree relatives, people sleeping in the same house, classmates and teacher at school.

Given the risks of using fluoroquinolones in children, the Cochrane review is circumspect in advising the administration of ciprofloxacin to children. However, the HPA leave it to a paediatrician’s discretion to consider the risks of a single one-off dose and still suggest ciprofloxacin as first line consideration. Rifampicin (2 doses daily for 2 days) is now considered second line.

This month’s emergency department version of Paediatric Pearls has information on dehydration from the NICE guideline on gastroenteritis in the under 5s, a bit on seizures and the evidence behind our reluctance to let you request chest x-rays for children. I’ve featured the NICE guideline on antibiotics for respiratory illness in primary care too as they are also relevant for the children we see in EUCC and the Emergency Department. I hope you find it helpful; I think the average length of time for each infection is useful information to be able to hand on to parents. Download December’s Paediatric Pearls here.

December’s Paediatric Pearls (GP edition) reminds us all of the NICE guideline on antibiotic prescribing in respiratory tract infections. I would like to do a bit more of the “delayed prescribing” in the Emergency Department but it would require either the family coming back (ie. a “no antibiotic” policy really) or their putting a bottle of amoxicillin in their fridge and potentially not using it as we give out the actual antibiotic in A and E, not prescriptions. We’ve also featured a couple of papers showing that chest x-rays add very little to the management of a child with a respiratory illness which I think most GPs know but it doesn’t harm to remind trainees still in the hospital that, just because the radiology department is at the end of the corridor, it doesn’t mean you have to use it! We continue our 6-8 week baby check series with information on sacral dimples and I have also put in a couple of websites with sensible, empathetic information and advice on school refusal. The beginning of term is stressful for children who find it hard to go to school and parents may find these sites helpful when trying to understand why their child is behaving in that way. Happy New Year to you all!